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???????????????????????????????????????????????????????????????????????????????????????????????????? ????????????????????????????????????? 29 ?????? 2552????????? ???.??????????? ????????? 47230066????????????????? ?????********************************************************************************************************************??????????????????????????(INFECTIVE ENDOCARDITIS)?????????????????????????? ???? infective endocarditis (IE) ????????????????? ??????????????????????????????????????? ?????? ?????????????? ???????????? vegetation ????????????????????????????????????????????? ??????????????????????????? IE ??????????????????????? mitral valve, aortic valve, tricuspid valve ??? pulmonary valve ???????????????????????????????????????? ventricle ???????????????????????????????????????????????????? (ventricular septal defect;VSD) ?????????????????????? ductus arteriosus ?????????????? infective endarteritis ??????????????????????????????? 2 ?????? ??? acute bacterial endocarditis (ABE) ????????????????????????????? ???????? ?????????????????????????????????? ?????????????????????????????????????? ???????????????????????? 6 ??????????????????????????? ?????? subacute bacterial endocarditis (SBE) ????????????????????????????????? ????????????????? viridians streptococci, Streptococcus epidermidis ??? enterococci??????????????????????????????????????????????????????? ????????????????????????????????? Chlamydia, Rickettsia, Mycoplasma ????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????? ???????????????????????????????????????????????????????????? ????????????????????????Native valve endocarditis (Native valve IE)???????????????????????? ???????????????????????????????????????????????? ???????????????????? ??? ??????????????????????? ???? valve regurgitation, rheumatic heart disease ??????????????????? ??????????????????????????????????????? ???????????????????????????????????????????????????? ???? aortic stenosis, mitral regurgitation ???????????????????????? staphylococci, streptococci, viridians streptococci, enterococci ??? HACEK organismsProsthetic valve endocarditis (Prosthetic valve IE)???????????????????????????? ?????????? 2 ???? ??? ????????? 60 ??? ????????????????????????????????????????? early onset ?????????? 2 ??????????????????????? 12 ????? ???????????? late onset ????????????????????????????????? ??????? Coagulase negative staphylococci (S.epidermidis) ???? S.aureus ???????????? late infection ?????????? streptococci ??? HACEK organismsNosocomial infective endocarditis???????????????????????????????????????????????? ??????????????????????????????????????????????????????????????? ???????????? nosocomial IE ?? predisposing factors ????????? IE ??????????????????????????????? (venous catheter) ??????????? ? ??????????????????????? ????????????????????????????????????? ????????????? ?????? coagulase negative staphylococci, S.aureus, enterococci ??? MRSAInfective endocarditis in intravenous drug user (IDU infective endocarditis)?????????????????????????????????????????? ??? tricuspid valve, aortic valve, mitral valve ??????????????????????????????? ???? S.aureus ????????? IVDU ???????????? HIV ????? Pseudomonas aeruginosa, Salmonella spp., Listeria spp., ?????????? ??????????????????????????????????????????????????????????????????? ???????????? (constitutional symptoms) ?????? ??? ???????? ????????? ????????? ?????????? ????????? ????????????????????? ???????????????????? ?????????????????????????????????????????????????????????? ????????? ??????????????????? ????????????? ????????????????????????????? ????? ???????????? ?????????????????????? (>38?C) ??????? heart murmur ???????????????????????? ?? ?????????? ????????????????????????????????????????? ???? subconjuctival hemorrhage, splinter hemorrhage, Osler’s node (?????? ?????????????????? ???????) Roth’s spot (?????????????? choroids plexus ?? retina) Janeway’s lesion (?????? ????????? ???????????????) ??????????????????????????????????????????????? ????? normocytic normochromic anemia, WBC ??????????????????????????????? ????????????????? ESR ???????????????????????????? infective endocarditis????????????????????????????????? vegetation ??????????????????? ?? metabolic rate ??? ???????????????????????????????????????????????????????????????????????? ??????????????????????????? bactericidal ????????????????????????????????????? vegetation ????????????????????????????????? ??????????????????????????????????? ?????????????????? ?????????????????????????????????????? ? ????????????????????????? ??????????????????????????????????????????? MIC ???????????????????????????? ?????????????????????????????????????????????????? ?????????????????????????????????????????????? 48-72 ??????????????????????????????? ??????????????????????????????????????? ?????????????? 3-5 ?????????????????????? 1 ?????????????????? native valve endocarditis ?????????? ????? viridians group streptococci ??? streptococcus bovis ?????????? penicillin (highly penicillin-susceptible; MIC ≤ 0.12 ?g/mL)RegimenDosage and route????????????????(???????)????????????????????Penicillin G sodium12-18 mU/day IVPediatrics; 200,000 U/kg/day IV ????????????????? 4-6 hr4IA-???????????????????????????????????????????? 65 ?? ????????? renal impairment ???? cranial nerve ?????? 8 ???????Ceftriaxone sodium2 g IV/IM ODPediatrics; 100 mg/kg IV/IM OD4IAPenicillin G sodium 12-18 mU/day IV ????????????????? 4-6 ??????? + gentamicin 3 mg/kg IV OD ?????????????? 8 hr2IB-??????????????????????????????????? cardiac/intracardiac abscess ???????????? CrCl < 20 mL/min ???? cranial nerve ?????? 8 ???????-???????????????? peak ??? 3-4 ?L/mL ??? trough < 1.0 ?L/mLCeftriaxone sodium 2 g IV/IM ODPediatrics; 100 mg/kg IV/IM OD + gentamicin 3 mg/kg IV OD ?????????????? 8 hr2IBVancomycin30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr)Pediatrics; 40 mg/kg/day IV ?????????? 8-12 hr4IB-????????????????????????????????????????? penicillin/ceftriaxone-????????????????????????????1.Peak 30-45 ?L/mL(1hr post dose)2.Trough 10-15 ?L/mL-??????????????????? IV ??? ? ???????????????? 1 ??????????????????????????????? red man syndromes???????? 2 ?????????????????? native valve endocarditis ?????????? ????? viridians group streptococci ??? streptococcus bovis ?????????????????? penicillins (relatively penicillin-resistant; 0.5 ?g/mL ≥ MIC ≥ 0.12 ?g/mL)RegimenDosage and route????????????????(???????)????????????????????Penicillin G sodium 24 mU/day IV????????????????? 4-6 ??????? + gentamicin 3 mg/kg IV OD ?????????????? 8 hr4IB-?????????????????????? penicillin ????????????????????????????????????? enterococcal endocarditis????????????????Gentamicin 2 ???????Penicillin/ceftriaxone 4 ???????Ceftriaxone sodium 2 g IV/IM OD; Pediatrics: 100 mg/kg IV/IM OD + gentamicin 3 mg/kg IV OD ?????????????? 8 hr4IBVancomycin 30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr) Pediatrics: 40 mg/kg/day IV ?????????? 8-12 hr4IB-????????????????????????????????????????? peniciliin/ceftriaxone???????? 3 ?????????????????? prosthetic valve endocarditis prosthetic materials ??????????????? viridians group streptococci ??? streptococcus bovisRegimenDosage and route???????????????? (???????)????????????????????Penicillin-susceptible strain: MIC ≤ 0.12 ?g/mLPenicillin G sodium24 mU/day IVPediatrics: 200,000 U/kg/day IV ????????????????? 4-6 ???????6IB-????????????? gentamicin ???? 3 mg/kg/day IV OD ??? 2 wks ???????????????????? combination therapy ?????????????? monotherapyCeftriaxone sodium2 g IV/IM ODPediatric: 100 mg/kg IV/IM OD6IBVancomycin30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr)Pediatric: 40 mg/kg/day IV ?????????? 8-12 hr 6IB-????????????????????????????????????????? penicillin/ceftriaxonePenicillin-relatively resistant/resistant strain: MIC > 0.12 ?g/mLPenicillin G sodium 24 mU/day IV; Pediatrics 300,000 U/kg/day ????????????????? 4-6 ??????? + gentamicin 3 mg/kg IV OD ???? ?????????? 8 hr6IBCeftriaxone sodium 2 g IV/IM OD; Pediatrics: 100 mg/kg IV/IM OD + gentamicin 3 mg/kg IV ?????????? 8 hr6IBVancomycin 30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr) Pediatrics: 40 mg/kg/day IV ?????????? 8-12 hr6IB-????????????????????????????????????????? penicillin/ceftriaxone???????? 4 ?????????????????? staphylococcal endocarditis ???????????????????? prosthetic materialsRegimenDosage and route???????????????? (???????)????????????????????Oxacilllin-susceptible strainsNafcillin/oxacillin 12 g/day IV ?????????? 4-6 ??????? ???? Penicillin G 24 mU/day IV ?????????? 4-6 hr (????????????????? penicillin; MIC ≤ 0.1 ?g/mL) ± gentamicin 3 mg/kg IV OD ?????????????? 8 hr6IA????????????????Gentamicin 3-5 ???Penicillin/nafcillin/oxacillin 6 ??????? ?????? left/right side IE ??? 2 ??????? ?????? umcomplicated right side IE-clinical benefit ??? AMG ?????????????????Cefazolin 6 g/day IV ?????????? 8 hr ; pediatrics 100 mg/kg/day IV ?????????? 8 hr ± gentamicin 3 mg/kg Iv ?????????? 8 hr6IBOxacillin resistant strainsVancomycin 30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr) Pediatrics: 40 mg/kg/day IV ?????????? 8-12 hr6IB??????????????????????????????????-Peak 30-45 ?L/mL (1 hr post dose)-Trough 10-15 ?L/mL???????? 5 ?????????????????? staphylococcal endocarditis ?? prosthetic heart valve endocarditisRegimenDosage and route???????????????? (???????)????????????????????Oxacillin-susceptible strainsNafcillin/oxacillin 12 g/day IV ?????????? 4 hr ???? Penicillin G 24 mU/day IV ?????????? 4-6 hr(????????????????? penicillin; MIC ≤ 0.1 ?g/mL)+ rifampicin 900 mg/day IV/PO ?????????? 8 hr+ gentamicin 3 mg/kg IV OD ?????????????? 8 hr≥6IB????????????????-Gentamicin 2 ???????-Nafcillin/oxacillin/rifampicin ????????? 6 ??????? Cefazolin 6 g/day IV ?????????? 8 hr; pediatrics 100 mg/kg/day IV ?????????? 8 hr+ rifampicin 900 mg/day IV/PO ?????????? 8 hr+ gentamicin 3 mg/kg IV OD ?????????????? 8 hr≥6IBOxacillin resistant strainsVancomycin 30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr)+ rifampicin 900 mg/kg/day IV/PO ?????????? 8 hr+gentamicin 3 mg/kg IV ?????????? 8 hr(2 wks)Pediatrics: 40 mg/kg/day IV ?????????? 8-12 hr+ rifampicin 20 mg/kg/day IV/PO ?????????? 8 hr+gentamicin 3 mg/kg IV ?????????? 8 hr (2 wks)≥6IB????????????????-Gentamicin 2 ???????- Vancomycin/rifampicin ????????? 6 ?????????????????????????????????????????-Peak 30-45 ?L/mL (1 hr post dose)-Trough 10-15 ?L/mL???????????????????????? beta-lactams ??? anaphylaxis/immediate type???????? 6 ?????????????????? Native valve ??? prosthetic valve endocarditis ???????? Enterococci ???????? penicillin, gentamicin ??? vancomycin (Penicillin/gentamicin/vancomycin susceptible strains of enterococci)RegimenDosage and route???????????????? (???????)????????????????????Ampicillin 12 g/day IV ?????????? 4 hr ???? PenG 18-30 mU/day IV ?????????? 4 hr ???? Continuous IVPediatrics: ampicillin 300 mg/kg/day IV ?????????? 4-6 hr ???? PenG 300,000 mU/kg/day IV ?????????? 4-6 hr ???? Continuous IV + gentamicin 3 mg/kg IV ?????????? 8 hr4-6IA????????????????-Native valve IE 4 ??????? ????????????????????? 3 ????? ??? 6 ????????????????????????? 3 ?????-Prosthetic valve IE ????????? 6 ??????? Vancomycin 30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr) + gentamicin 3 mg/kg IV ?????????? 8 hrPediatrics: 40 mg/kg/day IV ?????????? 8-12 hr + gentamicin 3 mg/kg IV ?????????? 8 hr6IB????????????????-Gentamicin 6 ???????-Vancomycin 6 ????????????????????????????????? short course AMG (2wks) ??????????????????????????????????????????????-???????????????????????? beta-lactams ??? anaphylaxis/immediate type???????? 7 ?????????????????? Native valve ??? prosthetic valve endocarditis ???????? enterococci ???????? penicillin,streptomycin ??? vancomycin ?????????? gentamicinRegimenDosage and route???????????????? (???????)????????????????????Ampicillin 12 g/day IV ?????????? 4 hr ???? PenG 24 mU/day IV ?????????? 4 hr ???? Continuous IV+ streptomycin 15 mg/kg/day IV/IM ?????????? 12 hr Pediatrics: ampicillin 300 mg/kg/day IV ?????????? 4-6 hr ???? PenG 300,000 mU/kg/day IV ?????????? 4-6 hr ???? continuosus IV+ streptomycin 20-30 mg/kg/day IV/IM ?????????? 12 hr4-6IA????????????????-Streptomycin 4-6 ???????-Ampicillin/pen G 4-6 ???????-????? 4 wks regimen ??????????????????????????? 3 ?????-????? 6 wk regimen ??????????????????????????? 3 ?????Vancomycin 30 mg/kg/day IV ?????????? 12 hr (??????? 2 g/24 hr)+ streptomycin 15 mg/kg/day IV/IM ?????????? 12 hrPediatrics: 40 mg/kg/day IV ?????????? 8-12 + streptomycin 15 mg/kg/day IV/IM ?????????? 12 hr6IB????????????????-streptomycin 6 ???????-vancomycin 6 ??????????????????????????????? beta-lactams ??? anaphylaxis/immediate type???????? 8 ???? ?????????????????? Native valve ??? prosthetic valve endocarditis ??? ????? Enterococcal ??????? aminoglycosides ??? vancomycin ?????????? penicillin RegimenDosage and route???????? (???????)????????????????????Beta-Lactamase producing strainsAmpicillin-sulbactam 12g/day ?????????? 6 ??.+Gentamicin 3mg/day IV/IM ?????????? 8 ??.6IIaC????????????????-Gentamicin-Ampicillin-sulbactam 4-6 ??.??????????????????????? AMG,???????????????????? Amp/Sul ?????????? 6 wksVancomycin 30 mg/kg/day IV ?????????? 12 ??. (??????? 2g/24 hr)+Gentamicin 3 mg/kg/day IV/IM ?????????? 8 ??.6IIaC???????????????????????? beta-lactams ??? anaphylaxis/immediate typeIntrinsic penicillin resistanceVancomycin 30 mg/kg/day IV ?????????? 12 ??. (??????? 2g/24 hr)+Gentamicin 3 mg/kg/day IV/IM ?????????? 8 ??.6IIaC???????? 9 ???? ?????????????????? Native valve ??? prosthetic valve endocarditis ???????? Enterococci ?????????? penicillin, AMG ??? vancomycin RegimenDosage and route???????? (???????)????????????????????Enteroccus faeciumLinezolid 1200mg/day IV/PO ?????????? 12 ??.≥8IIaC-??????? cardiac valve replacement-????????????????????????????? linezolid ??? thrombocytopenia ???????????? 2 ?????????????????????-Quinupristin/dalfopristin ???????????? severe myalgia ???????????????? ??????????????????????????Enterococcus faecalisImipenem 2 g/day IV ?????????? 6 +Ampicillin 12 g/day ?????????? 4 ??.≥8IIbCCeftriaxone 4 g/day IV/IM ?????????? 12 ??. +Ampicillin 12 g/day ?????????? 4 ??.≥8IIbC???????? 10 ?????????????????? Native valve ??? prosthetic valve endocarditis ????????????? HACEK organismsRegimenDosage and route???????? (???????)????????????????????Ceftriaxone 2 g/day IV/IM OD4IB??????????? gen 3 Cephalosporins ???????? ceftriaxone ?????????????Ampicillin-sulbactam 12g/day ?????????? 6 ??.4IIaBCiprofloxacin 1000 mg/day PO ???? 800 mg/day ?????????? 12 ??. ?????????? 12 ??. (??????? 2g/24 hr)+Gentamicin 3 mg/kg/day IV/IM ?????????? 8 ??.4IIbC-????? fluoroquinolones ?????????????????????? betalactams ?????????????? levofloxacin/moxifloxacin ???????????????? ciprofloxacin ???-???????? FQs ????????????? <18 ??-??????? prosthetic valve/materials ?????????? FQs ??? 6 wks?????????? (Prophylaxis for infective endocarditis)???????? 11 ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????? ???????????????????????? palliative shunt ???? conduit???? 6 ?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????American Heart Association, Rheumatic fever endocarditis and Kawasaki disease ????????????????????????????????????? infective endocarditis ????????????????????????????????????????????????????????????????????????? (procedure) ????????? ?????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????? endocarditis ?????????????????????????? infective endocarditis ?????????????????????????????? ?????????????????????????????? ???????????????? ????????????????????? antimicrobial prophylaxis ??????????????????????????????????????????????????????????????????????????? ?????? ????????????????????????????????????????????????????????????????????????????? (gingival tissue or periapical region ) ????????????????????????? oral mucosa???????????? ?????????????????????????????????????? ??? ??????????????????????????????????????????? ??????????????? ????????????? ??????????? orthodontic appliance ?????? orthodontic bracket ???????????????????????????????????????? trauma ??????????????? oral mucosa???????? 12 ???????????????????????????????????? infective endocarditis ???????????????????????????????????????????????????????????????????????????????????????????????????Amoxicillin2 g50 mg/kg????????????????????????????AmoxicillinCeftiriaxoneCefotaxime2 g IV/IM1 g IV/IM1 g IV/IM50 mg/kg IV/IM50 mg/kg IV/IM50 mg/kg IV/IM?????????? penicillin/ampicillin ????????????CephalexinClindamycinAzithromycinClarithromycin2 g600 mg500 mg500 mg50 mg/kg20 mg/kg IV/IM15 mg/kg IV/IM15 mg/kg IV/IM?????????? ?????? penicillin/ampicillin ??????????????????CefazolinCeftriaxoneClindamycin1 g IV/IM1 g IV/IM600 mg IV/IM50 mg/kg IV/IM50 mg/kg IV/IM50 mg/kg IV/IM?????????????? 1st ???? 2nd Cepphalosporins ????????????????????? cephalexin ???????????????????????? penicillin/ampicillin ??? anaphylaxis ???????????? angioedema/urticaria ????????? cephalosporin?????????????Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2007;138:739-60.Baddour LM, Wilson RW, Bayer AS, Fowler VG, Bolger AF, Levison ME, et al. Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: Endorsed by the Infectious Disease Society of America. Circulation 2005;111:e394-e434. ................
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